When I was a lad, if you were ill you tried homemade remedies first – mostly pretty horrible. When I had a cold with a cough and green “snot” the doctor gave me antibiotics. I didn’t question it.

When I trained to be a doctor I was given lots of technical knowledge and excellent diagnostic skills and I learnt which treatment went with which diagnosis.

As a GP I used to ask patients what they thought the matter was. Most replied that it was up to me to tell them and then prescribe the right pill. Sometimes I told patients about side effects and sometimes they listened but were often surprised when they got them.

I used to decide what tests were needed and patients usually turned up for the test. Sometimes tests cause more uncertainties rather than produce answers.

So “doctor knows best”. I don’t think so. And Choosing Wisely Wales doesn’t think so and nor do many others.

The clinician (not just the doctor) is an expert in diagnosis and knowing what tests and treatments may help. The patient (or individual with the health problem) is the expert about their body, their life and their community.

Both can access information about health, disease, tests and treatment from the internet, books, magazines and friends. The clinician has the expertise in assessing how good or relevant that information is and the patient is best able to apply that to their own circumstances providing they understand the words and messages.

How about if clinicians and patients had more equal conversations more often? Ones perhaps more open and honest where the patient gets the opportunity to explain how they feel, how their problem impacts on their life, what they are worried about, what is important to them and what they expect or hope will (or will not) happen.

The clinician explains what the likely problem is and what evidence (research) suggests should be done. They also explain what improvement to expect but also what risks there may be and how easy it will be to provide the care.

The patient asks for more information. What else could we do? What harm might happen? How likely am I to get better? Will I be able to do what I need to do next week or the week after? What will happen if we do nothing? What can I do to help myself?

There won’t always be definite answers and sometimes there just won’t be enough time but this conversation will help make a shared decision more common. It means both patient and clinician are taking responsibility for the choices made both appreciating that whilst a good outcome is likely there is a risk something unintended might happen.

We know many treatments in the NHS can cause harm. That isn’t the intention but it happens. We know which treatments or tests are more likely to cause new problems than solve current ones. It makes sense to avoid those most of the time.

Choosing Wisely Wales is part of an international movement led by clinicians in partnership with patients. It aims to change or rebalance clinical conversations recognising patient and clinician as near equal partners bringing different knowledge and skills to reach an agreed plan to improve the wellbeing of one of them.

It is recommending that patients be more confident in asking four questions about suggested tests and treatment. It encourages clinicians to explain the options or choices for patients based on appropriate evidence, which is shared in the conversation.

Choosing Wisely Wales suggests several tests and treatments that should normally be avoided as of low benefit but which may occasionally be of value. It suggests alternatives to be discussed and recognises that the final choice rests with the clinician and patient together.

Dr Paul Myres is the programme lead for Choosing Wisely Wales and Chair of the Academy of Medical Royal Colleges Wales. He is also a GP in Wrexham.

Choosing Wisely Wales was launched in September and is part of an international movement. It is led in Wales through a partnership of the Academy of Medical Royal Colleges in Wales, Board of Community Health Councils and Public Health Wales and supported by Welsh Government.

The first time I ever saw or heard of Sepsis it was on a death certificate. The death certificate was my brother’s. I remember squinting across the registrar’s table at this little word next to “primary cause of death.” It meant nothing to me.

My brother was… is… Mark. He was 41 years old, married with a 3 year old daughter. He had a family and a future.

At midday on Thursday 31st May, 2012 Mark walked into A&E (London) with stomach pains. By 17.15p.m. he had suffered a cardiac arrest. By 19.00p.m. he was on a ventilator with a 50/50 chance of survival. By 01.00a.m. on Friday 1st June, his kidneys had failed, his odds had shortened and his family were on the M4 having received the phone call nobody wants. The next morning his heart was too weak for dialysis. We know now that he was in septic shock. Multiple organ failure. He fought hard on his last day as did all the ITU staff. Everyone gave everything but sepsis won. He died peacefully lunchtime on Saturday 2nd June.

We couldn’t believe how this had happened. He had a stomach bug. How could we have lost a son, a brother, a husband, and Sophie a dad? Well, what I know now which I didn’t know then is that it can happen, it does happen and it happens far too often. In fact it happens 44,000 times a year in the UK. 2,200 times in Wales. I thought we were one in a million. We were not.

Sepsis is a car crash illness. It is indiscriminate and can affect anyone. It kills nearly a third of all the people it touches. That’s more than breast, bowel and prostate cancer combined. Shocking isn’t it? You know what’s also shocking? If spotted early it’s treatable and preventable.

It’s fair to say that sepsis changed my life. It does that to lives.

Not long after Mark died I met Ron Daniels of the United Kingdom Sepsis Trust and began raising awareness in Wales. I’m now Executive Director of UK Sepsis Trust in Wales. I’ve met Ministers, cycled from West Wales to Westminster fund raising, I speak in schools, at hospitals, to the people in shops and on buses. We have engaged Welsh Government in our work, a cross-party group has been established. People are listening.

I listen too; to survivors and how they have struggled post sepsis, to the bereaved and how they struggle too.

Awareness and education is everything. People need to know what sepsis is and what it can do. We need to get to a stage where public and health professionals alike are thinking about and recognise sepsis. They need to see it coming because it hides really well. As Mohammed Ali said, “His hands can’t hit what his eyes can’t see” Ironically he recently died from sepsis.

I’ve been helped along the way by some wonderful people both inside and outside healthcare. . I am on the RRAILS steering group. As such, I’ve seen first-hand the incredible hard work of dedicated NHS Wales staff committed to improve practice to improve outcomes. The programme is doing some great work striving to educate NHS Wales staff on Sepsis. We want the same thing.

We’ve even won an award for it! It was fantastic for The Global Sepsis Alliance to recognise and reward NHS Wales for its awareness and education initiatives.

But..

We cannot afford to lose momentum. There can be no resting on laurels. We should celebrate what has been done, be proud but also continue to challenge and champion what still needs to be done. For me, there has to be a collective effort from Community to Cabinet. We need a common language for patients and practice. The patients need a pathway, an All Wales pathway. If we speak about sepsis the same, we can think about sepsis the same. It brings us together and as we say here in Wales… “together, stronger”.

I was so pleased to have the opportunity to attend the Patient Safety Congress. I have been keen to get involved and find out more about 1000 Lives Improvement and this was an opportunity to spend time with members of the team and learn from healthcare professionals all over the world that would be in attendance. It was great to meet fellow nursing student Bianca Jourdain from Swansea University.

From the beginning I felt empowered by Dr Suzette Woodward, director of ‘Sign up to Safety’ who valued pride for patient safety and recognised that staff should be cared for when involved in incidents. Dr Woodward spoke of compassion, trust and human conversations which link with the fundamentals of care that I am learning in my first year as an adult nursing student. The words which resonated with me the most are:

“Learn as much as possible and never be judgemental”.

Dr Claire Gordon, Consultant in Acute Medicine at Lothian University Hospitals NHS Trust explained how planning is important in patient care with involvement from the patient and the multidisciplinary team. Clear plans should be used however small such as ‘today Mrs Jones the plan for you is to walk ten steps’. The use of planning and ‘leading indicators’ was also spoken of by Professor Maxine Power, Director of Haelo, who also valued communication with the whole team when planning improvement. “Staff need to be aware of what they are measuring and why”. Receiving feedback means staff can see the process is worthwhile and continue to measure. Always Events® took this another step further and suggested that improvement planning should involve patients, families, carers and staff.

Technology featured prominently at the Congress. There were many companies offering electronic recording for patients’ observations with automatic escalation to the doctor and prompts, reminders and task management. Datix also attended, they showed their reporting of incidents to Bianca and I. We then achieved the second highest score on their quiz, coming second only to their own manager – another win for us both and we got to take home @thedatixbear as a reward.

Students Amanda and Bianca with the Datix bear

Strong themes of trust and teamwork prevailed across the talks over the two days which was widely considered to promote openness and courage for staff to report and learn from incidents without the worry of blame. Whilst a large aspect of the Congress explored new technology for collecting and analysing data; it was evident to me that the culture within the teams was fundamental to achieving this. The need for clinical competence and judgement was highly regarded: not to over rely on checklists and numbers – sometimes a patient is ‘just not right’ and we should not be afraid to act on this.

Patient safety wasn’t the only lesson for me – I also mastered the use of chopsticks when we went to China Town for supper!

I found it sad when the Congress came to an end but was reminded by Dave Hill, Service Improvement Manager at 1000 Lives Improvement, that this is just the beginning of my journey. This experience has increased my enthusiasm and commitment to quality improvement as part of my nursing career. Thank you 1000 Lives Improvement for making it possible and for making Bianca and I feel like part of the team.

When I entered the ‘A day in the life of a patient’ competition, I saw it as an opportunity to raise awareness of paediatric nursing and apply what we’re taught at university in terms of putting yourself in the shoe of your patients. However, winning it has enabled me to learn so much more than this. As a competition winner I attended the 2016 Patient Safety Congress in Manchester. With over 2,000 health professionals from clinical and non-clinical backgrounds attending, there was a vast assortment of knowledge and experience present throughout the two days.

Dr Suzette Woodward, one of the opening speakers on the first day, suggested that as health professionals, we should “learn to do the job, on the job” when discussing the education and application of patient safety. This was evident throughout the Congress as the stalls and speakers reiterated that we are trying to improve, and not replace current healthcare services and medical interventions. There were several notable themes including the use of technology to advance current practice and the need to adopt a family-centred and holistic approach, working with patients and not for them to provide the best possible care.

The interactive side of the Congress revolved around social media via Twitter allowing delegates such as myself to not only see what was happening all over the Congress, but to also get actively involved. Furthermore, the use of Sli.do, an internet based service that I had not used before, allowed direct engagement with each speaker through polls and questions.

Over the course of the two days, three sessions in particular really stood out for me: namely Cathy Sheehan, Clinical Lead for Children Protection at NHS England who gave ‘An integrated approach to safeguarding children’; Dr Daniel Cohen and Dr Stephen Webb’s ‘Investigating harmful events due to delays in diagnosis’ and the NICE Forum’s ‘The cancer drugs fund: The new arrangement’.

There were personal development opportunities at the Congress too. I asked a question in front of what felt like hundreds of people (using a microphone) and conversed with speakers after their presentations about the topics they had discussed. It was a great opportunity to meet other delegates and professionals from across the UK, learning about their fields, interests and backgrounds.

The Congress wasn’t the only positive outcome of entering the competition. I was able to explore a busy, beautiful city that I had not seen before (I would especially recommend visiting the John Rylands Library). I also met Amanda, an adult nursing student from Bangor University who shared the same enthusiasm for our chosen profession, and of course the 1000 Lives Improvement team, who had no hesitation in making us feel welcome and involved us throughout.

An additional highlight of the Congress was winning the Datix patient safety quiz with Amanda (and scoring ourselves teddy bear prizes!). I enjoyed every minute of this experience and I wouldn’t have been able to gain the exposure and knowledge of quality improvement and patient safety that I now have if it wasn’t for 1000 Lives Improvement, and for that, I am very grateful….Thank you!!

What is Quality Improvement?

Quality Improvement (QI), or Improvement Science, uses a systematic approach to design and implement changes in healthcare. Knowledge of the methodology of QI is essential when considering improvements to the modern complex healthcare environment. QI is also included as part of many postgraduate training curricula.

In March 2016, the AoMRC published its report: Quality Improvement – training for better outcomes, which sets out recommendations for quality improvement education and training. The report has drawn together a wide range of organizations to align efforts to implement quality improvement training as a core competence in modern clinical practice, from undergraduate curricula through specialist curricula and beyond into Consultant practice.

The report represents a starting point for future development and aims to provide a structured framework to embed improvement methodology as a core competence for all doctors.

It is recognized that significant barriers remain, with a lack of parity in access to QI training and resources across organizations and specialties. For many senior doctors and other members of the multi-professional team, the concept of QI remains a new idea.

The rotational nature of medical training means that doctors in training, working within multi-professional teams, are well placed to share areas of good practice and support QI development.

QI Training in Anaesthesia and Intensive Care Medicine in Wales

The Welsh School of Anaesthesia working in partnership with 1000 Lives Improvement have developed a QI Training programme for both doctors in training and trainers, to provide high quality training in the principles of QI and access to QI training resources to support innovation and excellence in healthcare.

This programme aims to provide high quality QI Training through the use of interactive workshops for trainees and support the development of QI networks of both trainers and trainees across Wales. Furthermore, it is hoped that as part of the programme, access to high quality QI projects will be enhanced and individuals will be well supported in developing their own projects. The programme includes the courses outlined below:

Quality Improvement in Anaesthetics – a 2 Day Interactive Workshop for Specialty Trainees

The Welsh School of Anaesthesia working in partnership with 1000 Lives Improvement offers an interactive workshop for trainees in Anaesthesia & Intensive Care Medicine in Wales.

The course provides the opportunity to learn from experts in quality improvement, who have experience of successful QI projects, to advance your own knowledge and skills in this area.

Candidates have the opportunity to develop their own QI project as part of the workshop, working in small groups to gain valuable hands on practical guidance. Attendance at both days of the workshop and submission of a successfully completed project results in the award of IQT Silver Level Accreditation.

As part of this programme, a further QI Training Workshop for specialty trainees in anaesthesia will be held this autumn. Dates will be confirmed shortly and will be published on the Welsh School of Anaesthesia website.

Quality Improvement in Anaesthesia: Introduction for Trainers (1 Day Course)

This 1-day introductory course for trainers focuses on the principles of Quality Improvement.

The course provides the opportunity for trainers in Anaesthesia in Wales to build on their knowledge of QI and its role as part of training in Anaesthesia and Intensive Care Medicine.

The course enables trainers to gain an understanding of the methodology and framework that underpins QI and its role in improving healthcare. Participants will also have access to contacts with experience in this area that will be able to provide further support for QI initiatives locally.

Future areas for development:

As part of the ongoing development of the educational programme to support QI Training in Wales, there will be a number of new opportunities for trainers and trainees this autumn:

Welsh School of Anaesthesia Educational Supervisors Study Day, October 2016

The workshop will provide some background of the present scope of QI Training and provide the opportunity for trainers in Wales to gain an understanding of the methodology and framework of this developing area of postgraduate training, as part of an interactive workshop.

Society of Anaesthetists of Wales, Autumn Meeting, October 2016 will also include a presentation on QI Training in Anaesthesia in Wales by a member of the QI development programme, Dr. Katy Beard.

Working in partnership with other Specialty Schools to support QI Training in Wales

At present, members of the programme development team are working with the All Wales School of Emergency Medicine to develop a QI Training programme for Specialty trainees in Emergency Medicine. This includes supporting trainers to develop a QI training network as well as mapping QI training areas against the requirements of postgraduate curricula.